All right, next is the cartilage restoration panel. We're really excited about the superstars that we have both nationally and internationally here. On their way up, I'd like to introduce them briefly. Ramon Cugat, International Superstar in Biologics. Ramon is the President of the Medical Council for Catalan Soccer Delegation and the Director of the Cugat Center, Associate Professor of Barcelona University. Elisa Vita-Cohn is the immediate Past President of ICRS and Professor at her University of Humanitas, University in Milano. And Austin Stone is here in the United States with us at the University of Kentucky. He's an Assistant Professor, Team Physician for University of Kentucky, as well as Eastern Kentucky. And also is a PhD in Molecular Medicine and Translational Sciences, specializing in cartilage injuries. So we're gonna extract as much from Austin as we can today. And then finally, last but not least, Misty Suri here from the Ushner Center of Sports Medicine in New Orleans, former Team Physician for New Orleans Pelicans and Saints, current for Xavier, University of New Orleans, Dillard University, Delgado University, Suno University, and the list goes on for Misty. So thank you, this is exciting. Dr. Papacostas, let's do the first case. So thank you for being here so late. It's just across the, just before the break, I guess. Thanks for having us here. And I need to thank, of course, my co-chair, moderator, Jason. So this is the first case. I think it's a little bit challenging. As you can see, he's a very high professional football, soccer, name it, player. Plays in the highest possible level, Techno 10. 24 years old, captain of his team, playing in a very big, not in a very big level championship, but in a very high standard. Suffering from early June, without any injury, suffering problems, having problems, after having a meniscectomy, 25%, 20, 25%, but good hoop fibers, three years prior to that. Starting having problems, symptoms, and tried almost everything, including two months definitely out of any activity. Trying to get back again, all forms of physical therapy, inter-articular injections, you name it, even including cortisone, hyaluronic acid, PRPs are like two or three sessions. And of course, medication, including biphosphonates. He also had two or three extra outside the country consultations. So, consecutive MRIs, like three or four MRIs in this three, four months period, like from June, 2021 to October, 2021, you can see what you can see in the MRI. So, what's your impression? Let's start with the European part. Ramon. Ramon. Diffuse media femora condylydema, clinical situation, he cannot do single leg squat, he cannot jump, he cannot change direction, even started affecting his daily activities. Perfect. I think the pain for me is the edema. That's the most important. And in these cases, my treatment is inject inside the bone PRP, plus study the alignment. If it's necessary, the wedge in the shoes, in the left shoe, the wedge about four, five millimeters for the defect of the medial meniscus, this 25, 35%. But the pain, if it's a soccer player, I repeat it, PRP, inject, and the echographic control, or the fluoroscopy, inject about seven, eight cc. Depends how is the pressure at the moment we inject and heals perfect. I know your vast experience of this, and I also know that Lisa is working a lot on the intra-oscious injections. To be honest, in this case, in these four months prior to our consultation, he did everything else apart from the intra-oscious. Lisa, would you consider arthroscopic evaluation? Do you think that there's something there? No, I don't think it's something there. So I agree with Ramon, he's using PRP, I'm using VMAC in these cases, or SWF, not fat preparations, but SWF, more purified. So you might give it a try. It's the first week you have to calm down. You know, in three months, he have done all possible treatments, but probably this thing will go away just in six months without doing nothing. So it might be, because it's overload, it's post-mensectomy, it's not have a characteristic of osteonecrosis or CF. So it's something that he have to calm down, have to not to visit any other people for six months and see what will happen. So it's probably will go away by itself. Working in a full professional environment. I know, I know, it's not easy. Coming to the American side, what would you do? What would you, knowing that the patient is high-level sports, he definitely have access to other colleagues, so he can ask for opinions. This way, but from this point of view, I agree with what Ramon said, you know, you're doing triosteus injection and there he stayed quiet for three months for sure. So maybe it works. So it's... How about you guys? I think intraosteus injection's reasonable. He also has evidence of arthrogenic muscle inhibition if you look at his quad. So I'd add as part of that, the BFRT in conjunction with functional neuromuscular stimulation, while he's taking it easy for that to heal so that he comes back stronger and faster. That's a good option. Yeah, I think intraosteus injection is mandatory here. You got to do it quick. And he wants to get back to playing this season. In my hands, I would do a intraosteus injection of a bone marrow substitute of various types, hydroxyapatite-based or whatever yours is that you have access to. And in my experience, they do pretty well. And I would tell the player he's got a great chance of playing this season quickly. So we pretty much answered what's the next step for you and what to expect. That's the reality. November, early November, 21st, 2021. So nobody went for it? No, the question was what he wanted to do and what he felt that he tried. And so the option was from our side, intraosteus, but also check- With the scope, yeah. With the scope to see what's going on. And then you have this. This is post-minutiae chemicondrolysis, probably. It was just a flap, which apparently it was delaminated. And that's the case. What to do now? In this case? I give you also the dimensions. It was like after de Bruyman, it was almost 2.5. For him, which is 5'7", if I'm not wrong, it's 170. I mean, the relative size is a little bit over the medium-sized defect. In this case, for me, it's to do an arthroscopy, make the revision, all the knee joint, if there's any loose body, and then- This was not a loose body. This was the intraoperative finding. Okay. Just after- Cut it, all this cartilage, and remove it. And leave it. The borders are very close, attached at the bone. And then this cartilage, I cut it, mince pieces, and mix with PRP, and create in a mesh. And at the moment, I open, open, mini-open the arthrotomy. And then I stick it, the minced pieces of cartilage, plus the PRP, and the moment is not liquid, and not just gel. That is the moment, and leave it one week with the full extension. And then, after one week, start to move in, and six weeks without weight-bearing. And that is possible to get the yalen cartilage, because they are the same phenotype of the minced pieces of cartilage, and the same PRP from the blood of the same soccer player. Let's keep our answers short, until we get some more cases. Coming from this side, Misty, what would you do? So, obviously, preoperative discussion, you need to talk about options, what could happen, delamination, all these things are possible with the MRI, so he's gotta be prepared to miss the season, if that's the case, of course. So, in this case, osteocondylograph would be a potential option. Okay. Awesome. My definitive treatment would be an osteochondral allograft. Lisa? I would probably put inside the agility, so osteochondral or not having osteochondral allograft, so, anyway, reconstructive. Something reconstructive, also on the bone level. Okay. Some points. The athlete wants the best possible solution, not a fast return, so not just debride it and leave it as it is. Of course, you also raised the issue of bone edema and osteochondral unit. The relative size of the defect is also important. What do you expect coming from this side now? With your approach, return to play? Realistically, with full rehab, returning to play, it'd be eight to nine months. Full, full play. Yeah, close to that. I would get a CT scan in a professional athlete, assess the bone healing at six months and advance a little bit more quickly then. 10 at least. Normally, in this match, it's about seven, eight months. Someone at the professional play at four months, but was not permitted for me. I think it's better now. I mean, the solution I chose is similar to your choice, Ramon. Seven. With good results and finally he came back, played and still plays one and a half year after, missing almost one season. It was, his first game was 10 months after, for three minutes, but in one year, he played 90 minutes. How about a second case? This is a 38-year-old Army officer and many years of pain that just wasn't getting better with essentially anything. He's got a small effusion, a little tight patellofemoral complex, but he wasn't really patellofemoral-wise malaligned. Right, so the TTTG is below. Here's his arthroscopy. So this is a big problem, obviously involving the trochlea, the cartilage and the bone. Real quick, now, what is the best treatment for trochlear lesions like this, kind of wide escaping in your hands? Let's start with Misty and come on back this way. His support was, I'm sorry? Army officer. So for this patient, scope, cleanup, that's it? That's it. I would, well, I would do tibial tubercle osteotomy definitively with the scope and cleanup. Okay, and then to clarify, so then normal TTG, so you're really doing an anteriorization osteotomy, still doing it oblique? Talk us through real quick. Yeah, primarily I would have a steeper angle, make a crosscut, so I wouldn't medialize as much, and that would be primarily anteriorization, so I'll tolerate a few millimeters of medialization with the TTTG of 15. Lisa? How was with patella? Patella was good, so of all things. Sobria will do some reconstruction on the cartilage side of the trochlea. Okay, and then your choice, though, when it involves the cartilage and the underlying? Trochlea welds pretty well with biological scaffolds. The trochlea is the best, basically. So it depends a little bit on analysis, maybe combined with the tibial tubercle scaffold. Ramon? The same I use in this case, cut it, all the borders, and to fill it with the same minced pieces of cartilage around we cut it, plus growth factors, and that is natural, and that is very good to restore the yalen cartilage. So I've had a little less luck than you guys with the scaffolds and these big lesions, and so then when, with something more structural and somebody who still has really high demands, here's the question that we wanna get from you guys, your expertise. It's pretty widely known that osteochondroallograst of the trochlea is the most difficult technical procedure, right? And so then the question to the panel, again, going back and forth, number one, how do you match your osteochondroallografts, right, for the trochlea and the narrowness of the trochlea, et cetera? And then number two, how do you get the contours right? When you're doing this and taking a few measurements might not be applicable now because, again, of its curvature and fall of the trochlea, take us through the technical part of this, of getting results of matched trochlea in the native patient's trochlea. Misty, you wanna start again? I mean, I just go preoperatively, try to get it with the scans and match it up as best we can. Interoperatively, I think you slide your graft harvest area a little proximal distal, and that can help you a little bit, not a lot, but a little bit to get a sort of eye, better eye, by eye to get your better match. Do you have a request, anything like sulcus angles from the transplant foundations, et cetera, to try to get a closer match, or you just say size alone, medial to lateral, and go with that? I just go with size alone because I've tried to get that, and it doesn't, it's not always what I think it is. Got it. Austin? Yeah, I've borrowed a pearl from Adam Yanke, where you can take the sizer, and if you color it with the skin marker, you can place it on the trochlea, and you can get a little bit more accurate measurements there so I've used that pearl from him. Lisa, do you guys have this technology? We don't have it in Italy basically available. Here, another possibility would be an episode where the technology will be presented in the previous session. This would be much better here than in the case we have seen in the debate. We've got, just real quick, we've got multiple athletes, high-level athletes, as you know with basketball, with teleform lesions like this that are uncontained that are playing at that level for many, many years, and many of them have gotten just a scope cleanup for this uncontained lesion, and they carry on for many years, so that's kind of where that comes from. Yeah, but then we also have that other edge, right, and that's the part we don't understand about cartilage restorations that are completely debilitated from this, and unable to jump, et cetera, and what's the difference between those two athletes? I'm not sure, but that's the reason on this one I chose something a little bit more structural because he just was completely debilitated with it, and I thought we might fall short with just debridement, but touche, right, there's a big variance between patients. And also because he's in the army, also. Yeah. Can I go for the other cases? Oh, sorry, yeah, I think we're out of time, but thank you guys very much. Thank you.

cartilage restoration

PRP injections

meniscectomy

trochlear lesion

osteochondral allografts